In my local area over the past few weeks, I have heard quite a few people talking about the same thing – that is a recent article in the local paper stating that three major departments in our hospital are to be moved to the regional hospitals 50 to 60 miles away. As it turned out, the source of this story was proposals in our local sustainability and transformation plan (STP) which had been leaked to the press. This has caused a good deal of concern locally, with many people feeling fearful, confused and angry.
The experience of patients and public in my community is not unusual. Our recent report concludes that while STPs offer the best hope for delivering long-term improvement in health and social care, they have been beset by problems so far – including a lack of time to adequately include clinicians, frontline staff, patients and the public.
An NHS communication earlier this year to all leaders involved in developing STPs stressed that the plans are not an end in themselves, but rather a means to build and strengthen local relationships, enabling a shared understanding of where we are now, our ambition for 2020 and the steps needed to get there.
So what needs to happen if we are to meaningfully include patients and the public in the STP development process in future?
I think a clue lies in the word ‘meaningful’. I believe it would be helpful if it was made absolutely clear by those leading the STP process how patients and the public (and other stakeholders) are to be involved. In my opinion this would require a choice: either employ traditional approaches to engagement with their focus on gathering evidence and data about people’s experiences using feedback mechanisms and representational structures (with their flaws and underlying assumptions about roles and responsibilities across professional and citizen boundaries); or work towards what the NHS five year forward view describes as a ‘new relationship’ with patients, citizens and communities. At The King’s Fund we have defined this as a ‘collaborative relationship’ rather than a ‘them and us’ relationship.
A focus on collaborative and relational practices will involve a genuine commitment to sharing power, developing the values, principles and practices associated with dialogue and co-productive working, and potentially challenging current mindsets and established working cultures. These are issues we have been exploring with patients, citizens, clinicians and managers on our ’collaborative pairs’ programme. And earlier this year we published Patients as partners, which sets out a practical framework for developing collaborative relationships among NHS, patients and community partners.
I understand that those leading the STP development process are currently having to manage conflicting demands and work pressures, and also deliver to incredibly tight deadlines. However, the danger is that under this pressure people can retreat into their professional and organisational silos and adopt practices that maintain control, rather than work towards change for the better.
I wonder what would happen if people were prepared to challenge their assumptions around how patients and the public might react if given full disclosure? It might feel like a risk, but in my opinion it is just a new way of working that feels risky because of the shift in power, control, identity and knowledge; in fact the risks of not doing so could be even greater. What might happen if a different conversation was initiated, involving local communities coming together with the leaders of local health and care services to engage in a dialogue about opportunities?
Yes, this might be challenging. It will certainly confront existing assumptions held by all groups about how others might react when they come together. It will also generate different ways of looking at our current dilemmas, potentially enabling us to see new ways forward. I am certain there are readers of this blog who will have their own examples of local initiatives where citizens, patients, voluntary/third sector organisations and statutory providers have come together in different and innovative ways to find a solution for a local health and care issue.
I believe it is now incumbent on the leaders involved in the STP development process to model the ethos and practice of collaborative and partnership-working, with its focus on dialogue and relationship building. This is not fundamentally a question of time or resources (although of course these are important factors) – for me it is a question of attitude, of will and of courage – and a mindset prepared to confront the need for change in our working culture in order to achieve the health care service we need and want.